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Record Keeping Requirements and Client Access to Clinical Records
March 1, 2006
What is it about clinical record keeping? All practitioners know they are supposed to keep records, yet a surprising number have excuses for not doing so: “It just got away from me;” “I am trying to protect my clients’ confidentiality; “I know I should;” “It’s not one of my strong points;” “I have poor handwriting.”
Treatment records are maintained for the clients’ benefit. Failure to maintain competent clinical records is an offense which could result in action being taken against your license. The recently revised regulations of the Board of Registration of Social Workers require a social worker to establish and maintain clinical records which are more detailed than many practitioners realize. The violation of these requirements can subject a social worker to discipline from the Board. The Board asks for a copy of the clinical record whenever a complaint is fi led against a social worker at the Board, regardless of the underlying reason for the complaint. What may start out as a defensible complaint can mushroom into something more serious if there is no record or if the record is poorly maintained. Poor records also deprive the practitioner of the benefit of the doubt. Basically, poor records make you look bad. In malpractice cases, failure to keep records can itself be evidence of malpractice.
Here then are the current requirements for establishing and maintaining clinical treatment records, along with my occasional comment in italics.
Establishment of Clinical Treatment Records
A social worker who provides clinical social work services shall establish and maintain a separate, legible, adequate and accurate written clinical treatment record for each client receiving such services. (Clear records are for the client’s benefit. The “graphically challenged” are advised to maintain notes on a computer with a printed copy in the file). This clinical treatment record sh all be maintained in accordance with accepted standards of professional social work practice, shall identify the client to whom it pertains, and shall contain:
a. A description of the client’s prior history of services, if any (obtaining treatment history is only possible if the client is willing to disclose it; the client’s unwillingness to disclose should be specifically noted);
b. A description of the client’s present reasons for seeking clinical social work services;
c. An assessment or diagnosis of the client’s mental, emotional or behavioral condition, disorder or addiction;
d. Documentation of any changes or revisions in the assessment or diagnosis of the client’s mental, emotional or behavioral condition, disorder or diagnosis which occur during the provision of clinical social work services by that social worker;
e. A treatment plan which sets forth the treatment goals and objectives established by the client and the social worker, describes the nature of the clinical social work services provided and identifies the treatment modalities used;
f. Documentation of any changes or revisions in the treatment plan which occur during the provision of clinical social work services to that client by that social worker;
g. A description of the frequency and duration of the services provided;
h. Progress notes containing the social worker’s assessment of the client’s progress in treatment; (The best practice is to measure progress against the treatment plan);
i. Recommendations and/or plans for further treatment or services for the client, where appropriate;
j. Documentation of any fees charged, payments obtained, and other relevant billing and/or insurance information;
k. Documentation that the client has been informed of his or her confidentiality rights;
l. Copies of all client authorizations for release of information or records; (As a general rule, do not rely on oral releases. If something is not in writing it does not exist); and
m. Any other information reasonably necessary to permit proper assessment and treatment of the client in the future. (The termination process should be thoroughly documented).
Length of Record Retention
Except as otherwise provided by law, a client’s clinical treatment record shall be maintained for a period of not less than seven (7) years from the date of the last client encounter or professional consultation with the client. In the event that the client is a minor, the client’s clinical treatment record shall be maintained for at least seven (7) years from the date of the last client encounter or professional consultation with the client, or at least three (3) years after the client attains the age of majority (currently 18), whichever is longer.